Provider Demographics
NPI:1417939273
Name:DEGROFF, STEVEN A (OD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:A
Last Name:DEGROFF
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 FOREST PARK DR
Mailing Address - Street 2:P.O. BOX 30
Mailing Address - City:BERNE
Mailing Address - State:IN
Mailing Address - Zip Code:46711-1745
Mailing Address - Country:US
Mailing Address - Phone:260-589-3197
Mailing Address - Fax:260-589-2911
Practice Address - Street 1:150 FOREST PARK DR
Practice Address - Street 2:
Practice Address - City:BERNE
Practice Address - State:IN
Practice Address - Zip Code:46711
Practice Address - Country:US
Practice Address - Phone:260-589-3197
Practice Address - Fax:260-589-2911
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002194B152WC0802X, 152WS0006X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN18002194-BOtherOPTOMETRY LICENSE #
IN300006820Medicaid
IN18002194-BOtherOPTOMETRY LICENSE #